Jersey Mike’s EmployeesWelcome Jersey Mike’s employees! Employee's Full Name * First Name Last Name Employee's DOB * MM DD YYYY Social Security Number * Employee Tobacco Use? * Yes No Gender * Employee's Phone Number * (###) ### #### Employee's Email * Reason for New Enrollment * New Hire Newly Eligible Add Spouse Add Dependent Effective Date of Enrollment * On the first day of: January February March April May June July August September October November December Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Employer * Employee Job Title * Date of Hire * MM DD YYYY Coverage Tier * Employee Employee & Dependents Employee Salary * Dependent #1 Dependent #1 Tobacco Usage? Yes No Dependent #2 Dependent #2 Tobacco Usage? Yes No Dependent #3 Dependent #3 Tobacco Usage? Yes No Dependent #4 Dependent #4 Tobacco Usage? Yes No Dependent #5 Dependent #5 Tobacco Usage? Yes No Thank you for your submission. We look forward to working with you.
